Register for The Optometric Retina Symposium
at Walt Disney World

1. Prefix Dr.Mr.Mrs.Ms.
2. First Name
3. Last Name
4. Degree M.D.O.D.Other
5. Company
6. Gender MF
7. Date of Birth (MM/DD only)
8. Address
9. City
10. State
11. Zip
12. Phone
13. Email

1. 0 1 2 3 4 5 6 7 8 9 10 Attendee Package* (all inclusive) - $495 pp

   • Seminars
   • Friday Welcome Reception in Exhibit Hall
   • Breakfast Saturday & Sunday
   • Lunch Saturday
2. Promotional Code

*Registration does not include accommodations. A special room rate has been secured for the symposium. To receive this rate call Disney's Yacht & Beach Club (407) 939-7429 and mention "Optometric Retina Symposium."

1. Referred by

1. Payment TypeCheckCredit Card
2. Credit Card TypeVisaMastercardAmerican ExpressDiscover
3. Credit Card Number
4. Expiration Date January February March April May June July August September October November December 2012 2013 2014 2015 2016 2017
5. Security Code
6. Name on Card

1. I have read the refund policy and understand my options. This must be checked before submitting.